Culturally Competent Disaster Nursing

Lessons learned from Hurricane Katrina underscore the need for post-disaster nursing care that is more sensitive to the cultural needs of communities of color

by Luis Clemens

Natural disasters are colorblind in terms of whom and how they strike. “When a disaster hits, it doesn’t hit by race, color or creed. It hits people who are humans and bleed,” says Marilyn Pattillo, PhD, GNP, CNS, deputy team commander of the Federal Emergency Management Agency (FEMA)’s National Nurse Response Team. Yet, how disaster victims react to displacement, illness and stress is very much culture-based.

“Cultural competence is an integral part of any disaster behavioral health intervention,” says Nadine Mescia, MHS, associate director of the Florida Center for Public Health Preparedness at the University of South Florida College of Public Health in Tampa. “In order to be effective, [health workers responding to disasters] must be aware of cultural differences among survivors and patients.”

This issue has taken on additional urgency in the aftermath of the heavily criticized government response to the devastation wrought by Hurricane Katrina. The delayed and muddled relief efforts were perceived by many African Americans as the product of institutional racism.

Nurses responding to natural disasters have precious little control over how government resources are apportioned, but they do have control over how they treat patients. The consensus among many nurses who responded to Katrina is that cultural competence was the norm in the immediate wake of the hurricane. This was because the first wave of responders consisted of local nurses with first-hand knowledge of the affected communities’ cultural needs.

What Went Wrong

However, significant shortcomings in cultural competence arose in the following weeks and months, as new waves of disaster responders from across the nation–who lacked the local health professionals’ cultural familiarity with the affected communities of color–began to arrive.

Jennifer Field Brown, PhD, APRN, is the only white professor in the Nursing Department at historically black Norfolk State University in Virginia. When asked by the federal Substance Abuse and Mental Health Services Administration to work in a Louisiana shelter some six weeks after Katrina hit, Brown admits she was excited and jumped at the opportunity. But the racial and cultural tensions she observed during the two-week assignment have left her thinking for months.

“Many of the nurses were angry with the [largely African American] population that was still at the shelter,” she says. “There were many times when evacuees [said], ‘they don’t care about us.’”

Brown believes this perception was fueled by the cultural gap between the predominately poor and African American evacuees and the mostly middle class and white shelter staff. “[Some of] the response workers were appalled that some of the evacuees would not cash their checks because they had no family member with a checking account, [or] that they’d cash their checks and buy a TV. [The prevailing attitude among many of the shelter staff seemed to be] if you didn’t lose anything you are not entitled to anything.”

Deshotels, whose parents grew up in New Orleans, points out that strained race relations are not a new phenomenon in the Crescent City. “Because we have such a long history of racism and oppression [here], there is an always an air of tension and mistrust,” he says.

New Orleans used to have–and perhaps still has–a majority black population. Katrina scattered tens of thousands of the city’s African Americans throughout much of the country, so it is impossible to know for sure. But much of the city’s longstanding black middle class and working class have been displaced and have not returned. Cheryl L. Nicks, RN, CNNP, CGT, CLNC, CPLC, president of the New Orleans chapter of the NBNA, has been in touch with only three out of 65 members since the hurricane struck. She says, “Our chapter has basically been demolished.”

Caught Unprepared

Another shortfall in culturally competent health care that has worsened in New Orleans post-Katrina is the result of a dramatic and largely unforeseen population shift. In the place of many African American evacuees have come many thousands of Hispanic workers hired to help clean up and rebuild the city. Their arrival, a direct consequence of the hurricane, has amplified the difficulties the city’s public health system already faced in treating Hispanic patients.

The Roman Catholic Archdiocese of New Orleans created the Latino Health Access Network (LHAN) three years ago in response to the lack of sufficient health services for the Hispanic community. Shaula Lovera, director of LHAN, cites the absence of any evacuation information in Spanish as what she considers a typical example of the neglect faced by the Hispanic population before Katrina.

Now, the huge influx of Hispanic workers has dramatically increased the need for Spanish-speaking nurses and doctors. What used to be a small community of 14,000 in 2004 has grown to become a significant minority population whose access to health care is challenged by cultural, linguistic and economic barriers.

“These workers don’t make great salaries,” Lovera explains. “They have no access to Medicaid or Medicare. They don’t get health insurance from their employers.”
But often the biggest obstacle, she says, is simply navigating the hospital admissions process, with its personnel who don’t speak Spanish and its English-language forms that must be signed.

Before the hurricane, LHAN ran a Saturday clinic staffed by Spanish-speaking volunteer physicians and nurses. In 2002, before the clinic was established, only 2% of patients using LHAN’s services were Hispanic. But the number shot up to 17% after the clinic opened in 2003. This proves that Spanish-language medical attention was urgently needed, says Lovera.

The clinic, which was run by the Daughters of Charity, was badly damaged during the hurricane. Given the difficulties faced by Latino workers in getting treatment at local hospitals, LHAN has opted to bring bilingual nurses and doctors directly to the worksites. They give workers tetanus shots to guard against infections from accidents on the job and treat a series of common medical complaints. The lack of work boots, masks and gloves means that broken bones, sinusitis and cuts are a constant problem.

While this approach has been helpful, LHAN is stretched thin and has had to rely on volunteer doctors and nurses from outside the region. In lieu of always being able to find Spanish-speaking clinicians, they provide qualified medical translators.

Closing Knowledge Gaps

Based on these lessons learned the hard way, Lovera feels strongly that the federal government must focus on enhancing the cultural competence of disaster response teams. And she’s not alone. How agencies such as FEMA will respond to these recommendations from health professionals, if at all, remains to be seen. But in the meantime, a growing number of nursing educators are beginning to look at ways to fill this crucial knowledge gap.

Laura Terriquez-Kasey, RN, MS, CEN, is a member of a New York-based Disaster Medical Assistance Team (DMAT) that was sent to Louisiana following Katrina. The Department of Homeland Security’s National Disaster Medical System relies, in part, on a number of DMATs stationed throughout the country. The DMATs consist of highly skilled medical professionals that can be quickly deployed following a natural or man-made disaster.

Terriquez-Kasey’s previous disaster experience includes 9/11 and Tropical Storm Allison. “When I went into Allison and the flooding in Texas in 2001, we were a large group of nurses and it was very helpful to have the capacity to speak Spanish,” she says. Too often, Terriquez-Kasey believes, in the rush to “get everyone treated right away” the “cultural piece” of disaster nursing is simply overlooked.

It is an oversight that she tries to correct as a clinical lecturer at SUNY-Binghamton’s Decker School of Nursing. “There is a tremendous knowledge deficit in our health care where we don’t necessarily take the time to understand where the [patient] is coming from,” Terriquez-Kasey contends. “You can’t help someone if you can’t assess them, and if the patient doesn’t open up to you then you are really not doing your job.”

Take a Free Online Course in Culturally Competent Disaster Response

In 2004, the Florida Center for Public Health Preparedness at the University of South Florida (USF) in Tampa began offering a short online course called “Assuring Cultural Competence in Disaster Response.” The 1.5-hour course was developed by Jennifer Baggerly, PhD, LMHC, RPT-S, a professor at USF who responded to Hurricane Katrina as well as the 2004 tsunami in south Asia.

According to the center’s Web site, the course is designed to prepare public health professionals to offer culturally competent disaster interventions to survivors, witnesses and responders to bioterrorism and other major public health threats and community disasters. The course helps build competencies in such areas as:

• Identifying the role of cultural factors in determining and delivering disaster intervention services.

• Using appropriate methods for interacting sensitively, effectively and professionally with persons from diverse cultural, socioeconomic, racial and ethnic backgrounds, and persons of all ages and lifestyle preferences, when assisting disaster survivors, their family members, witnesses and disaster responders.

Baggerly says the purpose of the course is threefold. “The first reason is to prevent harm to the individual you are attempting to help. There are numerous examples of well-intentioned public health workers actually hurting [patients]. If you are not careful you can end up promoting harm. The second reason is for [health professionals] to be more effective and achieve faster results in recovery. Third, it protects the public health worker from harm. Sometimes [you can make] an unintentional faux pas that may anger some [patients].”

Anyone who signs up can take the online course for free, although you have to pay in order to receive continuing education credits. According to Baggerly, the course was envisioned as a convenient and immediate training option. “Especially in disaster response where [it is] very fast-paced, [health workers] are trying to respond quickly, so there is some anxiety that builds up.”

Nadine Mescia, MHS, associate director of the Florida Center for Public Health Preparedness, stresses the course’s importance by citing research that indicates “those who are at greatest risk for adverse outcomes following any disaster are. . .non-English-speaking [and] economically disadvantaged [persons].” The course, she says, helps bridge the cultural gap to those very groups.